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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306005326
Report Date:
07/28/2021
Date Signed:
07/28/2021 01:21:18 PM
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
770 THE CITY DR., SUITE 7100
ORANGE
,
CA
92868
FACILITY NAME:
CRESTAVILLA SENIOR LIVING
FACILITY NUMBER:
306005326
ADMINISTRATOR:
KEYS, BRIAN
FACILITY TYPE:
740
ADDRESS:
30111 NIGUEL RD
TELEPHONE:
(949) 345-1606
CITY:
LAGUNA NIGUEL
STATE:
CA
ZIP CODE:
92677
CAPACITY:
250
CENSUS:
145
DATE:
07/28/2021
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
11:35 AM
MET WITH:
Brian Keys
TIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the annual required inspection (mitigation control). LPA was greeted and granted entry by staff. LPA was required to check in and have his temperature recorded. LPA met with executive director (ED) Brian Keys. LPA and ED toured the facility. LPA observed facility has one entry point and all visitors must check in and are screened for Covid-19 symptoms. LPA observed all staff wearing masks. LPA observed all fireplaces are screened. LPA observed all fire extinguishers are fully charged. LPA observed the kitchen is clean and organized. LPA observed 2 day perishable and 7 day non-perishable food supply on hand. LPA and ED toured the memory care unit. LPA toured the patio area in the memory care unit. LPA did not observe any obstacles or hazards in the patio area. LPA observed the facility has a 30 day supply of PPE. Medication is kept secured in medication carts only accessible to staff. Mitigation plan (LIC 808) is pending approval. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of this report provided.
SUPERVISOR'S NAME:
Luz Adams
TELEPHONE:
(714) 703-2855
LICENSING EVALUATOR NAME:
Joseph Alejandre
TELEPHONE:
(951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE:
07/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/28/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
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